HESI EXIT VERSION 3 2020/2021

HESI EXIT VERSION 3 2020/2021 1. The nurse is reviewing medical prescriptions for newly admitted clients. It would be a priority for the nurse to follow up with the physician if a client with (a) a potassium level of 4.5mEq/L has Kayexalate (sodium polystyrene) prescribed (b) a Dilantin (phenytoin) level of 8 mcg/ml is placed on seizure precautions(c) sensitivity to Aspirin (acetylsalicylic acid) is prescribed Tylenol (acetaminophen) (d) sensitivity to Penicillin is prescribed Zithromax (azithromycin) 2. The nurse should intervene if the nurse notes a staff member (a) obtaining a clients consent prior to their operative procedure after receiving Ativan (lorazepam) (b) placing a client on the affected side following surgical repair of a retinal detachment (c) handling a wet cast with the palms of the hands (d) using a broad base of support while transferring a client 3. The community health nurse is caring for the following clients. It would be a priority for the nurse to initiate a multidisciplinary conference for the client who is (a) 12 years old with Autism who is starting a new school and recently had a URI (upper respiratory tract infection) (b) 16 years old, has type 1 Diabetes Mellitus, is unemployed and had a recent Hemoglobin A1c of 13% (c) 52 years old, with Myasthenia Gravis, recently prescribed Mestinon (pyridostigmine) and employed as a mail carrier (d) 70 years old, has schizophrenia, lives alone and reports hearing non threatening voices. 4. The nurse from the postpartum unit has been temporarily assigned to the medical surgical unit. It would be most appropriate to assign this nurse to the client who* (a) has returned from right total hip replacement surgery four hours ago (b) is being observed for increased intracranial pressure (c) had surgery two hours ago to remove the appendix (d) is two weeks post partum being maintained on a mechanical ventilator for respiratory failure 5. The nurse in a well baby clinic has assessed several children today. It would be a priority for the nurse to suggest follow up for the child who is (a) 2 months old with a positive babinski refl ex (b) 5 months old and does not hold their own bottle (c) 10 months old who cries around strangers (d) 18 months old who needs support while ambulating 6. The nurse is caring for a mechanically ventilated client who was declared brain dead. An Advance Directive is not documented on the medical record. It would be most appropriate to obtain consent for organ donation from the (a) client’s primary care provider (b) client’s nurse manager (c) closest living family member (d) hospital’s ethics committee 7. The nurse has received report on four clients. The nurse should fi rst assess the client who has* (a) Chronic Obstructive Pulmonary Disease (COPD) with a pulse oximetry reading of 90% (b) Parkinson’s Disease and is demanding to leave the hospital against medical advice (AMA) (c) been admitted with suspected Guillian-Barre´ Syndrome and has begun plasmapheresis therapy (d) Congestive Heart Failure (CHF) whose pitting edema has increased to 2(+) 8. It would be appropriate to assign which of these tasks to the CNA? (a) Feeding a client who is experiencing dysphagia (b) One-on-one client observation for safety (c) Removal of an indwelling catheter (d) Performing a simple dressing change 9. The nurse should intervene if a staff member is observed (a) discussing a client’s diagnosis with visiting family members (b) collaborating with another nurse to review a prescription for blood transfusion (c) interrupting other staff members discussing a client in the cafeteria (d) reviewing a clients lab values with the nutritionist 10. The nurse is preparing a staff presentation on legal and ethical issues in nursing. The nurse would be correct to include which of the following examples? (a) Putting a client in a geriatric chair with the lap tray in front of the client in the day room to watch television is false imprisonment (b) Telling a client that you will put in a feeding tube if the client does not eat is an example of battery (c) Telling a client with bipolar disorder who is suicidal that they have a right to refuse to take their medications is an example of malpractice (d) Placing hands on a client who says “do not touch me” is an example of assault 11. The nurse from the pediatric unit has been temporarily assigned to the Emergency Department. It would be most appropriate to assign that nurse to the client who* (a) reports epigastric pain that “feels like indigestion” (b) has back pain and a pulsating abdominal mass (c) is HIV+ reporting vomiting and diarrhea (d) presents with lower abdominal pain and is six weeks pregnant 12. Four clients recently returned to the unit following invasive diagnostic testing. The nurse should immediately intervene if one of the clients (a) reports blood tinged sputum following a bronchoscopy (b) has decreased abdominal girth following paracentesis (c) reports a headache following a lumbar puncture (d) is observed flexing and extending the legs two hours after cardiac catheterization 13. The nurse is made aware of the following situations. The nurse should fi rst check the client who (a) had a transurethral prostatectomy (TURP) and is reporting urinary dribbling two hours after the indwelling catheter is removed (b) has cervical traction and is moving the legs by fl exing and extending the feet (c) has Alzheimer’s disease (stage 1) and was returned to the room after being found wandering in the hallway (d) has a history of partial seizures and is sitting in the bed picking at the clothing and smacking the lips 14. The nurse in a community health clinic is talking with the parent of a child with Celiac Disease. Which of the following statements would require follow-up by the nurse for additional teaching? (a) “This weekend we are going to a seafood restaurant.” (b) “I can feed my child oatmeal and eggs for breakfast.” (c) “My child loves to eat rice and chicken for dinner.” (d) “Last night we ate fi sh with corn for dinner.” 15. The charge nurse is observing a Licensed Practical Nurse (LPN) performing care for assigned clients. Follow up will be required if the LPN*: (a) assesses a client’s apical pulse before administering Digoxin (lanoxin) (b) elevates the client’s stump on a pillow eight hours after amputation (c) dons a clean glove on the dominant hand before tracheal suctioning (d) positions a client on the operative side following a pneumonectomy 16. The nurse at a health promotion fair has taught a group of parents about car seat and seat belt safety. Which of the following statements, if made by the parent, would indicate a correct understanding of the information given? (a) “I will place my newborn infant in a rear facing car seat in the middle of the rear seat.” (b) “I will wear a lap seat belt high on my belly since I am 8 months pregnant.” (c) “I can use a front-facing car seat once my baby weighs 15 pounds.” (d) “I can allow my six-year-old to use a seat belt in the front passenger seat.” 17. The nurse is caring for a client being treated for Vancomycin Resistant Enterococcus (VRE). The nurse should place the client on (a) contact precautions (b) droplet precautions (c) protective precautions (d) airborne precautions 18. The nurse is caring for a client with a Vancomycin Resistant Enterococcus (VRE) wound infection. Which of the following actions would be appropriate for the nurse to take? (a) Wear a particulate respirator mask when providing wound care (b) Instruct visitors not to bring fl owers into the client’s room (c) Place the client in a private room with negative air pressure (d) Wear a disposable gown when changing the client’s dressing 19. The nurse should initiate protective precautions for a client who has a (a) Red Blood Cell Count (RBC) of 3,900/mm3 (b) Platelet count of 400,000μ/L (c) Hemoglobin (Hgb) 9.0 g/dl (d) White Blood Cell Count (WBC) 2,500/mm3 20. The nurse has provided health promotion teaching for a group of clients who were recently diagnosed with the Human immunodefi ciency virus (HIV). Which statement, if made by one of the clients, would require further teaching? (a) “I am glad that I can still clean my parakeet’s cage.” (b) “I will not go to the parade this weekend.” (c) “I will increase protein in my diet.” (d) “I will miss not being able to work in my garden.” 21. The nurse in the emergency department is caring for clients admitted following a rescue from a burning bus. The nurse should fi rst see the client who (a) has the tibia bone protruding through the skin and is in severe pain (b) has third degree burns of the left foot and is crying (c) is unconscious, pulseless, and has dilated pupils (d) has soot on the face and the nares and is coughing 22. A nurse is observing a newly-hired nurse provide care for assigned clients. The nurse should follow up if the newly-hired nurse is observed (a) wearing gloves when taking the blood pressure of a client with disseminated varicella zoster (b) cleansing the wound from the outer surface to the inner surface for a client whose wound is infected with a multi-drug resistant organism (c) washing the hands with the fi ngertips pointed downward before providing care for a client on protective precautions (d) removing the gloves before removing the gown when leaving a room of a client who is on contact precautions 23. The nurse is caring for a client who has been diagnosed with rheumatoid arthritis. The nurse should anticipate that the client will initially be prescribed (a) Disease-modifying rheumatic agents (DMARDs) (b) Nonselective anti-infl ammatory drugs (NSAIDs) (c) Long-term corticosteroids (d) Biologic Response Modifi ers 24. The nurse is assessing a 2-month-old-infant at a well baby clinic. The nurse should anticipate the infant should (a) roll from prone to back (b) have no head lag (c) smile socially (d) have no tonic neck refl ex 25. The nurse is teaching a class on infant nutrition. The nurse should instruct parents to introduce (a) fruit juices at 3 months (b) honey sweetened water at 6 months (c) pureed chicken at 7 months (d) whole milk at 9 months 26. The nurse is caring for a 7-year-old who has thrombocytopenia and is on protective precautions. Which of the following would be an appropriate toy for the nurse to provide to the client? (a) Finger paints and paper (b) A rubber ball and bat (c) A board game (d) A stuffed toy 27. The nurse on a pediatric unit has been informed that the following clients are being admitted. The nurse should fi rst plan to assess the client who is* (a) 2 years old, has a temperature of 100.8 F and a blood pressure of 68/44 (b) 4 years old with a history of asthma and has a peak expiratory fl ow rate (PERF) of 81% (c) 5 years old, has a fracture of the tibia and is reporting pain rated 7 on a pain scale of 0 (no pain) to 10 (severe pain) (d) 7 years old with ulcerative colitis and has had 15 blood tinged stools today 28. The nurse is providing discharge instructions to the parents of an infant who has a cleft lip. The nurse should instruct the parents to (a) place the infant in a prone position after each feeding (b) encourage the parents to provide the infant rest periods during feedings (c) regularly offer the infant a pacifi er to enhance the sucking refl ex (d) elevate the child’s head forty fi ve degrees during feeding 29. The nurse is assessing a 3-year-old during a well-child visit. During the visit the boy says to his mother, “Mommy, I love you. I’m going to marry you.” The nurse should (a) suggest to the mother not to encourage these types of statements (b) explain to the child that he will not be able to marry his mother even though he loves her (c) tell the mother that this statement is appropriate for his stage of development (d) recommend that the mother provide more opportunities for her son to play with other 3-year-old boys 30. The nurse is assessing a child with coarctation of the aorta. Which of the following would be an expected fi nding? (a) diminished blood pressure in the upper extremities (b) excessive weight gain (c) high pitched murmur (d) absence of femoral pulses 31. The nurse is caring for a child with an acyanotic heart defect. Which of the following would be an expected fi nding. Select all that apply. (a) ______ poor suck refl ex (b) ______ tachycardia (c) ______ increased respiratory rate (d) ______ bradycardia (e) ______ fainting spells (f) ______ delayed growth and development 32. The nurse is teaching a new mother about immunizations. Which of the following should the nurse include in the teaching? (a) “Your baby should wait six months to receive any immunizations since the baby was born preterm.” (b) “Your baby will receive the fi rst hepatitis B vaccine after one year of age.” (c) “Acellular Pertussis vaccine has less side effects than whole-cell pertussis vaccine.” (d) The Haemophilus Infl uenza Type b (HIB) is given annually to protect against the fl u.” 33. The mother of an infant tells the nurse that the baby has not been tolerating feedings lately and she noticed an olive-shaped mass in the infant’s abdomen. The nurse recognizes that this could be an expected fi nding if the infant has (a) intussusception (b) Hirschsprung’s disease (c) umbilical hernia (d) pyloric stenosis 34. The nurse is teaching a group of parents about the expected growth and development of three-year-old children. The nurse should include that a three-year-old should (a) discriminate between fantasy and reality (b) ride a tricycle independently (c) have a vocabulary of 7,000 words (d) play in a group of two or three with one being the leader 35. The nurse and the nursing assistant are caring for a group of clients. Which of the following client care activities should the nurse assign to the nursing assistant? Select all that apply. (a) _____ reinforcing the dressing of a client who has a decubitus ulcer (b) _____monitoring the vital signs of a client who had a myocardial infarction 12 hours ago and is being transferred from the coronary care unit (c) ______administering a prescribed Fleet’s enema to a client who will undergo a colonoscopy in two hours (d) _____ placing a client who had an above the knee amputation 24 hours ago in a prone position (e) _____ assisting a client who had a colon resection 36 hours ago to ambulate (f) _____ showing a client who had a vaginal hysterectomy 36 hours ago how to perform perineal care 36. The nurse is caring for a client with Acquired immunodefi ciency syndrome (AIDS) who was started on Zidovidine (AZT). It would be important for the nurse to assess (a) blood ammonia serum (b) serum potassium (c) complete blood count (CBC) (d) serum uric acid 37. The nurse is performing an abdominal assessment. Indicate the correct sequence the nurse should use to perform this assessment. (a) percussion (b) palpation (c) auscultation (d) inspection Answer______________ 38. The nurse has become aware of the following client situations. The nurse should fi rst assess the client who* (a) had received a unit of packed red blood cells four hours ago and is requesting a bedpan (b) had an abdominal hysterectomy yesterday and is reporting calf pain (c) has history of multiple sclerosis and is reporting diplopia (d) had a tonsillectomy three hours ago and is reporting a sore throat 39. The nurse is caring for a client who has been prescribed 1,000 ml of Ringer’s Lactate to infuse over 8 hours. The available intravenous set delivers 10 drops per milliliter. How many drops per minute should the nurse set the intravenous controller to administer? Answer ______________ 40. The primary health care provider has prescribed an oral solution of Potassium Chloride (KCL) 20 mEq PO, QD. The drug available is Potassium Chloride 10 mEq/15ml. How many ml should the nurse administer? Answer______________ 41. The primary health care provider has prescribed Heparin 5000 units SC. The drug available is heparin sodium 7500units/ml. Choose all of the correct answers for nursing considerations for the administration of heparin sodium. (a) ______ administer the heparin in the abdomen (b) ______ administer 0.5ml of heparin sodium (c) ______ aspirate after inserting the needle (d) ______ use a 1 inch 21 gauge needle (e) ______ refrain from massaging the site after administer heparin (f) ______ remember that protamine sulfate is the antidote for heparin 42. The nurse has attended a staff development conference on cultural considerations for clients receiving hospice care. Which of the following statements if made by the nurse would require follow-up? (a) The family of a client of the Buddhist faith may ask for a priest to be present at the time of death (b) The family of a client of the Jewish faith may request to have mirrors covered after the death of the client (c) The family of a client of the Muslim faith may request that the body of the client be turned to face the East at the time of the client’s death (d) The family of a client of the Hindu faith may request that the client body be bathed after the client’s death 43. The nurse is caring for a client with bipolar disorder who has Lithium (Lithotabs) prescribed. The nurse should suggest that the client have which of the following snacks? (a) A fresh fruit cup (b) Coffee and oatmeal cookies (c) Tuna fi sh salad on saltine crackers (d) Raw vegetables 44. The nurse has provided discharge instructions for a client who has been prescribed Digoxin (Lanoxin). It would require follow up by the nurse if the client says (a) “I will consult my primary health care provider before taking medications that contain aspirin.” (b) “I will not take any antacids within two hours of taking the digoxin.” (c) “I will avoid fruits such as avocados, grapefruit and cantaloupe.” (d) “I will remember that any visual disturbance can be a sign of digitalis toxicity.” 45. The nurse is caring for a client who has bumetanide (Bumex) prescribed. The nurse should suggest that the client include which of the following foods in the diet? (a) Apricots (b) Organ meats (c) Sardines (d) Apples 46. The nurse is providing teaching for a client with ulcerative colitis. Select all of the following that the nurse should include in the teaching (a) ______ steatorrhea commonly occurs or excessive secretion of fecal lipids is common (b) ______ ulcerative colitis occurs most frequently in Jewish males 30-50 years of age (c) ______ a diet high in residue and low in complex carbohydrates is helpful in controlling symptoms (d) ______ Corticosteroids may be prescribed during an exacerbation (e) ______ metronidazole (Flagyl) and ciprofl oxacin (Cipro) are antibiotics commonly used during acute exacerbations (f) ______ eating small frequent meals and lying down after eating promotes absorption of nutrients 47. The nurse is precepting a newly-hired nurse who is caring for a client receiving a prescribed continuous nasogastric feeding. The nurse should intervene immediately if the newly-hired nurse (a) instills 30cc of normal saline into the feeding tube while auscultating over the stomach for bowel sounds (b) checks the pH of the 60ml gastric aspirate removed from the feeding tube (c) maintains the client with the head of the bed elevated at 45 degrees (d) hangs four hours worth of prescribed feeding formula in an open delivery system 48. The nurse is observing a staff member caring for clients. It would require immediate intervention if the nurse observes the staff member (a) placing a client who had an above-the-knee amputation (AKA) 24 hours ago in a prone position (b) keeping the head of the bed elevated for the client who had an supratentorial craniotomy 12 hours ago (c) giving orange juice to a client who has a clear liquid diet prescribed (d) removing all liquids from the tray before giving the tray to a client who has dumping syndrome 49. The primary health care provider has prescribed ampicillin (Omnipen) 0.5 GM PO Q6H to a 15 month old toddler who weighs 22 pounds. The drug available is ampicillin suspension 250 mg/5 ml. The recommended dosage is 50 mg/kg/ day every 6 to 8 hours. The nurse should (a) call the primary health care provider to report that the prescription exceeds the recommended dosage (b) determine if the toddler has previously had a penicillin or a cephalosporin prescribed (c) give the toddler the ampicillin mixed with applesauce (d) wait until the result of the throat culture obtained one hour ago is reported 50. The nurse is instructing a class for parents of children diagnosed with sickle cell anemia. The nurse should instruct the parents to have the children avoid (a) exposure to hot water (b) other children with infections (c) medications containing aspirin (d) non - contact sports 51. The nurse is assessing a 5-month-old infant. The nurse should expect the infant to (a) roll from abdomen to back (b) sit without support (c) say ‘mama’ and ‘dada’ (d) prefer use of one hand over the other 52. The home health care nurse is assigned to see four clients who all live within three miles of each other. The nurse should fi rst see the client who has (a) gastroesophageal refl ux disease (GERD) and is reporting a burning abdominal pain that is relieved by walking (b) cancer of the esophagus who has given away a favorite shirt since the last visit (c) regional enteritis (Crohn’s disease) who has an elevated temperature and is vomiting (d) a gastrostomy tube who will begin self-feeding for the fi rst time 53. A student nurse is administering magnesium hydroxide/aluminum hydrate (Maalox) prescribed as an antacid to a client. The nursing instructor should intervene if the student plans to administer the antacid (a) two hours after the client has eaten a meal (b) at the same time as a prescribed iron preparation (c) after briskly shaking the bottle of Maalox (d) when assessing the client for the presence of gastric pain 54. The nurse has attended a staff development conference on vitamins and minerals. Which of the following statements if made by the nurse would require follow-up? (a) “Vitamin B12 (cobalamin) supplement may be needed if a client has a gastrectomy.” (b) “Vitamin D (calciferol) is necessary for proper utilization of calcium and phosphorous.” (c) “Vitamin A can be found in squash, pumpkin, and carrots.” (d) “Vitamin B6 (pyridoxine) supplements are given to help prevent macular degeneration.” 55. A nurse is caring for a two-month-old infant being evaluated for congenital hypothyroidism. The nurse should recognize which of the following fi ndings as being consistent with congenital hypothyroidism? (a) The infant sleeps for 6 hours at a time (b) The infant has a high-pitched cry (c) The infant has been having frequent loose stools (d) The infant has 3 + refl exes 56. The nurse in the emergency department is assessing a toddler who has swallowed some bleach. The toddler is crying. It would be a priority for the nurse to follow up if the parent says (a) “I brought the container of bleach with me.” (b) “I could not get my toddler to vomit.” (c) “I gave my toddler a tablespoonful of ipecac syrup.” (d) “I attempted to perform CPR to prevent my toddler from becoming unresponsive.” 57. The nurse is caring for a client who is ventilator dependent. The nurse is aware that the high pressure alarm can be sounded for various reasons. Select all reasons that could apply. (a) _____ increased bronchial secretions (b) _____ the presence of an air leak (c) _____ the presence of a kink in the tubing (d) _____ the client stops breathing spontaneously (e) _____ acute bronchospasm (f) _____ the client is biting the tube (g) _____ the ventilator tubing is disconnected 58. The nurse is caring for a client who has a new colostomy. The colostomy stoma is red, moist and slightly raised. The nurse should (a) determine if the client is allergic to the skin barrier (b) apply petroleum jelly gauze around the stoma (c) document the condition of the stoma (d) assess the client’s temperature 59. The nurse has attended a staff development conference on medical treatments for various neurological disorders. Which of the following statements if made by the nurse would require follow-up? (a) “Clients with Guillain-Barre´ syndrome (GBS) often have plasmapheresis prescribed.” (b) “Myasthemia Gravis can be treated with short-acting anticholinesterase drugs.” (c) “Parkinson’s disease may have catechol O-methyltransferase (COMT) inhibitors prescribed along with levodopoa-carbidopa (Sinemet).” (d) “Clients with Multiple Sclerosis often receive Intravenous immunoglobulin G (IV IgG).” 60. The nurse has attended a staff development conference on Meniere’s Disease. Which of the following statements, if made by the nurse would require follow-up? (a) “Meniere’s Disease symptoms result from excess endolymphatic fl uid in the inner ear.” (b) “Clients with Meniere’s Disease are encouraged to have a low salt diet.” (c) “Assistive listening devices are required for clients with Meniere’s Disease.” (d) “Stress is suspected to have a role in Meniere’s Disease.” 61. The nurse is admitting a client to the emergency department who is reporting progressive visual impairment and loss of peripheral vision. The nurse should recognize that these symptoms are consistent with the medical diagnosis of (a) macular degeneration (b) closed angle glaucoma (c) senile cataract (d) retinal detachment 62. The nurse is caring for a client who has left ventricular failure. Which of the following should the nurse recognize as being consistent with this diagnosis? (a) 3+ pedal edema (b) jugular vein distention (c) oxygen saturation of 96% (d) wheezing during expiration 63. The nurse has attended a staff development conference on preparing clients for neurological diagnostic tests. Which of the following statements, if made by the nurse would require follow-up? (a) “The electromyogram (EMG) is performed by introducing small needle electrodes into muscles.” (b) “After having a Positron Emission Tomography (PET) of the head the client can resume normal activities.” (c) “The electroencephalogram (EEG) will require the client to be NPO for 12 hours before the test.” (d) “After the lumbar puncture (LP) the client will need to lie fl at for about 3 hours.” 64. The nurse has become aware of the following client situations. It would be a priority for the nurse to intervene if a client (a) who had a cervical radium implant inserted sixteen hours ago is placed on bed rest (b) who had transsphenoidal hypophysectomy twelve hours ago is drinking fl uids through a straw (c) who has received prescribed Lithium for the past three days is observed eating a pickle brought in by a family member (d) who had retinal detachment repaired using a gas bubble four hours ago is lying on the operative side postoperatively 65. The nurse is caring for a client who has oxalate kidney stones. The nurse should teach the client to avoid (a) Spinach and rhubarb (b) Mushrooms and rice (c) Shell fi sh and aged cheese (d) Organ meats and wine 66. A client with end stage renal disease (ESRD) is scheduled for hemodialysis in one hour. The nurse should notify the primary health care provider that the client has a (a) BUN of 60 mg/dl (b) Creatinine 3.5 mg/dl (c) Sodium 145 mEq/L (d) Potassium 6.8 mEq/L 67. The nurse is caring for a 49 year old female client who reports having frequent vaginal yeast infections. The client is 35% over her ideal body weight. The client has had several diagnostic blood tests prescribed. It would be a priority for the nurse to review the results for an elevated (a) fasting blood glucose (b) white blood count (c) hemoglobin (d) blood urea nitrogen 68. The nurse at a health clinic is screening male clients for testicular cancer. It would be a priority for the nurse to teach testicular self examination to (a) a 17-year-old college football player (b) a 39-year-old who smokes a pack of cigarettes day (c) a 55-year-old with benign prostatic hypertrophy (d) a 69-year-old with a family history of testicular cancer 69. The nurse is caring for a 72-year-old client who was recently diagnosed with metastatic breast cancer. The client is expressing feelings of depression and is asking the nurse, “Why me?” According to Erikson, which developmental stage is the client experiencing? (a) Industry vs. inferiority (b) Ego integrity vs. despair (c) Generativity vs. stagnation (d) Intimacy vs. isolation 70. The nurse is caring for several clients who have been prescribed diuretics. The nurse should teach about increasing the consumption of citrus fruits and bananas to the client who has been prescribed (a) amiloride (Midamor ) (b) spironolactone (Aldactone) (c) torsemide (Demadex) (d) triamterene (Dyrenium ) 71. The nurse in a health clinic is reviewing prescribed medications with several clients. It would be a priority for the nurse to follow up with the client who states (a) “I am taking losartan (Cozaar) to lower my blood pressure.” (b) “I crush my verapamil (Calan SR) to make it easier to swallow.” (c) “I try to avoid sudden position changes since I am taking hydralazine (Apresoline).” (d) “I will not use any salt substitutes since I am taking captopril (Capoten).” 72. The nurse is developing a plan of care for a client diagnosed with fi bromyalgia. Which nursing diagnosis should the nurse include? (a) Sleep pattern disturbance (b) Risk for infection (c) Fluid volume defi cit (d) Urge urinary incontinence 73. The nurse has attended a staff development conference on sexually transmitted diseases. Which of the following statements, if made by the nurse would require follow-up? (a) “During the primary stage of syphilis a lesion occurs at the site of infection called a chancre.” (b) “A client with HIV who has a reading of 5 or more on the mantoux test is considered to have a positive fi nding for pulmonary tuberculosis.” (c) “Gonorrhea is often asymptomatic in women but causes urinary frequency and dysuria in males.” (d) “Chlamydial infections are strongly linked with cervical cancer in women.” 74. The infection control nurse is making rounds on a Medical Surgical unit. The infection control nurse should immediately intervene if a nurse is observed (a) wearing a disposable surgical face mask when entering the room of a client with active pulmonary tuberculosis (b) keeping the door to the room closed of a client with disseminate varicella zoster (c) leaving a dedicated stethoscope in the room of a client with respiratory syncytial virus (d) wearing a gown, gloves, and mask while taking the blood pressure of a client with Ebola Virus 75. The nurse in a community health setting is assessing the following clients. It would be a priority for the nurse to utilize a multidisciplinary approach for the client who is* (a) 12 years old, with chicken pox and cannot attend school (b) 21 years old, pregnant, unemployed and has active pulmonary tuberculosis (c) 32 years old, a grade school teacher and is recovering from a sickle cell crisis (d) 74 years old, with mild Alzheimer’s disease and is in an assisted living residence 76. The nurse working in the labor and delivery room has become aware of the following client situations. The nurse should fi rst assess the client who is (a) in the fi rst phase of labor and the fetal heart rate ranges from 128 to 140 between contractions (b) in the fi rst phase of labor and the fetal heart rate is consistently beating at 132 beats per minute (c) in the third phase of labor and the fetal heart rate has decelerated to its lowest point at the acme of the contraction (d) in the third phase of labor and the contractions are lasting 60-70 seconds 77. The nurse is caring for postpartum clients who had vaginal deliveries within the last eight hours. The nurse should fi rst assess the client who (a) has a pulse rate of 66 beats per minute (b) has saturated one perineal pad in two hours (c) reports swelling in her right calf (d) asks if her baby can sleep in the nursery tonight 78. The nurse has become aware of the following client situations. It would be a priority for the nurse to follow-up if a client who (a) had a total knee replacement 24 hours ago is using continuous passive motion (CPM) exerciser while in a supine position (b) is scheduled for a myelogram in 4 hours and states “I can not drink any liquids until after the procedure is fi nished.” (c) had a total knee replacement 24 hours ago and is sitting in a fowlers position to eat a meal (d) had a pin inserted 4 hours ago for a fractured femur has a small amount of bright red bleeding at the pin site 79. The nurse is teaching a client about crutch walking. Which of the following statements if made by the client indicates a need for further teaching? (a) “My elbows should be fl exed 20 - 30 degrees, while walking.” (b) “When I climb stairs I advance my affected leg fi rst, with my crutches.” (c) “I do not apply pressure under my arm when I use my crutches.” (d) “W hen I am going to sit in a chair I put both crutches in the hand on my unaffected side.” 80. The nurse on an orthopedic unit has become aware of the following client situations. It would be a priority for the nurse to follow-up if a client who (a) had a total hip replacement 8 hours ago has had 100 ml of bloody drainage in the closed wound suction device (b) has an external fi xation device after a repair of a fractured femur is requesting pain medication (c) had an open reduction and internal fi xation (ORIF) of a fractured femur 12 hours ago has developed a small rash on the chest and neck (d) had a total hip replacement three hours ago has a temperature of 37.8° C (100.2° F) 81. The nurse is caring for a client with a soft tissue injury. The client reports using a herbal remedy for 3 weeks prior to seeking health care but can not remember what was taken. The nurse should recognize that which of the following herbal remedies can be utilized effectively for soft tissue injuries? (a) Saint John’s Wort (b) Kava Kava (c) Dong–Quai (d) Aloe Vera 82. A client with left-sided weakness following a cerebral vascular accident (CVA) is learning to ambulate with a cane. The nurse should teach the client to (a) hold the cane on the left side and move the cane with the right leg (b) hold the cane on the right side and move the cane with the left leg (c) hold the cane on the left side and move the cane with the left leg (d) hold the cane on the right side and move the cane with the right leg 83. The nurse has become aware of the following client situations. It would be a priority for the nurse to intervene if a client (a) scheduled for an EEG is washing the hair (b) is being transported to have a magnetic resonance image (MRI) test and is attached to a pulse oximeter (c) is being taught to hold the breath at intervals during a computerized tomography (CT Scan) (d) on protective precautions is eating soup brought in by a visitor 84. The nurse is reviewing laboratory data of the following clients. It would be a priority for the nurse to follow-up with the primary health care provider if a client with (a) coronary artery disease has a low density lipoprotein (LDL) level of 129mg/dl (b) primary hypertension has a sodium level of 144mEq/L (c) rhinosinusitis has a white blood count (WBC) of 11,500/ul (d) diabetes mellitus type 1 has a glycosylated hemoglobin (HbA1c) level of 12% 85. The nurse working on a maternity unit has become aware of the following client situations. It would be a priority for the nurse to intervene if a client states (a) “I will not take my terbutaline (Brethine) if my pulse is greater than 110 beats per minute.” (b) “It is normal for my 10 hour old baby to have blue feet and hands.” (c) “I cannot breast feed because my nipples are cracked and sore.” (d) “I have changed my perineal pad every two hours since I delivered my baby 12 hours ago.” 86. The nurse observes an adult collapse on the street. Indicate the correct sequence for the nurse to follow. (a) phone emergency medical system at 911 -2 (b) verify unresponsiveness -1 (c) check for breathing -4 (d) establish an airway using a head-tilt/chin-lift -3 Answer ______________ 87 A nurse is admitting a client with suspected pulmonary tuberculosis (TB). Which of the following actions should the nurse take? (a) wear a gown when taking the client’s health history (b) place the client on droplet precautions (c) keep the door to the client’s room closed (d) use disposable gloves when taking the client’s blood pressure 88. The charge nurse of a medical-surgical unit notices a nurse walking with an unsteady gait, slurred speech and a faint smell of alcohol on the breath immediately following a lunch break. The charge nurse’s priority action would be to* (a) notify the nursing supervisor (b) asking the nurse about recent alcohol consumption (c) complete an incident report (d) relieve the nurse of assigned clients 89. The staff members of an out patient clinic have successfully assisted the clients to safety during a fi re in the waiting area. Which action should the nurse perform next? (a) Close all open doors (b) Call for additional help (c) Attempt to extinguish the fi re (d) Assess the clients’ vital signs 90. While performing an assessment of a 3-year-old client, the nurse notices bruises in various stages of healing on the concealed surfaces of the body. Which action should the nurse take next? (a) document the locations of the bruises in the medical record (b) notify the primary health care provider (c) contact the local reporting agency for suspected child abuse (d) ask the parent to